MEDICARE: JAMIE LYNN EDWARDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1457126070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE LYNN EDWARDS

Provider Business Mailing Address
First Line	:	712 PARKWOOD DR
Second Line	:
City	:	SIX LAKES
State	:	MI
Zip	:	48886-9786
Country	:	US
Telephone Number	:	616-824-6826
Fax Number	:

Provider Business Practice Location Address
First Line	:	712 PARKWOOD DR
Second Line	:
City	:	SIX LAKES
State	:	MI
Zip	:	48886-9786
Country	:	US
Telephone Number	:	616-824-6826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2023
Last Update Date	:	11/24/2023

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